The amazing power of compensation. Coming to a patient in your office… Maybe today

This gal has had a right sided knee replacement. She has an anatomical right short leg, a forefoot supinatus, an increased Q angle and a forefoot adductus. So, what’s the backstory?

When we have an anatomical short leg, we will often have a tendency to try to “lengthen“ that extremity and “shorten” the longer extremity. This is often accomplished through pelvic rotation although sometimes can be with knee flexion/extension or change in the Q angle. When the condition is long-standing, the body will often compensate in other ways, such as what we are seeing here.

IMG_6736.jpg

The fore foot can supinate in an attempt to lenthen the extremity. Note how the right extremity forefoot is in varus with respect to the rearfoot, effectively lengthening the extremity. As you can see from the picture, this is becoming a “hard“ deformity resulting in a forefoot varus.

IMG_6740.jpg

Over time, the forefoot has actually “adducted “ as you can see, again in an attempt to lengthen the extremity. Remember that supination is plantar flexion, abduction and inversion, all three which are visible here.


You will also see that the Q angle is less on the right side (se above), effectively lengthening that extremity, but not quite enough as we can see from the picture :-)



Dr Ivo Waerlop, one of The Gait Guys

#forefootadductus #shortleg #kneereplacement #tkr #forefootvarus #gait #thegaitguys

Podcast 109: A clinical case of a total knee replacement and achilles tendonopathy.

Great open clinical discussions today on things we see in the clinic. We start with a great case that opens up the dialogue, a case of a total knee replacement and achilles tendonitis.  Hope you will join us on this clinical journey today.

Interested in our store ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.tumblr.com) and you will come to our blog. In the left tab, you will find tabs for STORE, SEMIANRS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20). 

A. Podcast links:

http://traffic.libsyn.com/thegaitguys/pod_109f.mp3

http://thegaitguys.libsyn.com/podcast-109-a-clinical-case-of-a-total-knee-replacement-and-achilles-tendonopathy

B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

-Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show Notes:

Loose dialogue  on Anterior pelvis tilt and training it out

https://www.t-nation.com/training/dont-be-like-donald-duck?utm_source=facebook&utm_medium=social&utm_campaign=article3173

Ivo put up 2 articles recently on “Why is your muscle tight” and “iliocapsularis” muscle.
Why training the upper body might help integrate arms into gait for sporthttp://thegaitguys.tumblr.com/post/141990433844/gait-and-climbing-and-dns-part-2-introducing

http://journals.lww.com/acsm-msse/Abstract/publishahead/Influence_of_Step_Rate_on_Shin_Injury_and_Anterior.97596.aspx
- cross over looked at ?- ankle rocker looked at ?  endurance of anteiror compt looked at ?

tumblr_n7yjq09EgU1qhko2so1_1280.jpg
tumblr_n7yjq09EgU1qhko2so2_1280.jpg
tumblr_n7yjq09EgU1qhko2so3_1280.jpg
tumblr_n7yjq09EgU1qhko2so4_1280.jpg
tumblr_n7yjq09EgU1qhko2so5_1280.jpg
tumblr_n7yjq09EgU1qhko2so7_1280.jpg
tumblr_n7yjq09EgU1qhko2so9_1280.jpg
tumblr_n7yjq09EgU1qhko2so6_r1_500.jpg

So a patient presents to your office with a recent history of a L total knee replacement 8 weeks ago AND a recent history of a resurgence of low back pain, supra iliac area on the L side. Hmmmm. Hope the flags went up for you too!

His global lumbar ROM’s were 70/90 flexion with low back discomfort at the lumbo sacral junction, 20/30 extension with lumbosacral discomfort, left lateral bending 10 degrees with increased pain (reproduction); right lateral bending 20 degrees with a pulling sensation on the right. Extension and axial compression of the lumbar spine in left lateral bending reproduced his pain.

Neurologically he had an absent patellar reflex on the left, with diminished sensation over the knee medially and laterally. Muscle strength 5/5 in LE; sl impaired balance in Left single leg standing. There was incomplete extension of the left knee, being at 5 degrees flexion (right side was zero).

He has a right sided leg length deficiency (or a left sided excess!) of 5 mm. Take a look at the tibial lengths in the 1st 3 pictures. See how the left is longer? In the next shot, do you see how the knee cannot completely extend? Can you imagine that the discrepancy would probably be larger if it did?

Now look at the x rays. We drew a line across from the non surgical leg to make things clearer.

Now, think about the mechanics of a longer leg. That leg will usually pronate more in an attempt to shorten the leg, and the opposite side will supinate to attempt to lengthen. Can you see how this would cause clockwise pelvic rotation (in addition to anterior pelvic rotation)? Can you see this patients in the view of the knees from the top? Do you understand that the lumbar spine has very limited rotation (about 5-10 degrees, with more movement superiorly (1)  ). Does it make sense that the increased range of motion could effect the disc and facet joints and increase the patients low back pain?

So, how do we fix it? Have you seen the movie “Gattica”? Hmmm….A bit extreme. How about a full length 3mm sole lift to start, along with specific joint manipulation to restore normal motion and some acupuncture to reduce inflammation? We say that is a good start.

The Gait Guys. Increasing your gait literacy with each and every post. If you liked this post, please send it to someone else for them to enjoy and learn. 

(1) Three-Dimensional In Vivo Measurement of Lumbar Spine Segmental Motion Ruth S. Ochia, PhD, Nozomu Inoue, MD, PhD, Susan M. Renner, MS, Eric P. Lorenz, MS, Tae-Hong Lim, PhD, Gunnar B. Andersson, J. MD, PhD, Howard S. An, MD Spine. 2006;31(15):2073-2078.